DIABETES
MELLITUS has assumed alarming proportions all over the world but much
more ominously in the developing countries. It ranks seventh among the
leading causes of death and even higher if its fatal complications are
taken into account. Diabetes can lead to heart disease, brain stroke,
blindness, renal failure, loss of limbs and endless suffering because
it predisposes one to infections. In Britain, it has been estimated
that over 10 per cent of the budget of the National Health Service is
spent on diabetes and its related complications. Diabetes is like a
neighbour who is nice if you show him regard and consideration, but
becomes hostile if you ignore him. We all need to know some basic
facts about this ubiquitous disease.

The word diabetes (Latin)
means ‘running through a siphon’. The name was given because a
large amount of urine passes out in some varieties of diabetes. The
word mellitus means ‘sweet’ (in diabetes insipidus, a large
amount of water is passed out but no sugar).

India’s famous
ayurvedic physician and surgeon, Charak and Susharata, seem to have
made a large number of observations about this disease and named it madhumeha,
meaning ‘raining of honey’. Even at that stage they had
noticed that there were two varieties of diabetes mellitus, one with
stout built, gluttony and indulgent behaviour (modern type-II
diabetes) and the other one characterised by loss of weight, excessive
urine formation, thirst and increased appetite. During the 19th
century, a lot of observations were made regarding physiology and
association of this disease with Islets of Langerhans of the pancreas
which finally led to the discovery of insulin by the Nobel
prize-winning team of Banting and West in 1921. The first oral pill
for diabetes was introduced in 1955 by Franke and Fucks. Great
advances have been made in the understanding and treatment of diabetes
since then.

The basic ingredients
of human nutrition are carbohydrates or sugars, ready-made fuel for
energy, proteins, the tissue builders, and fats, also a source of
energy as well as the storage of energy. This diabetes is a
disturbance in the metabolism of carbohydrates in which the body is
unable to handle or regulate the level of blood glucose. Apart from
certain secondary causes of diabetes, like hormonal, nutritional and
other factors, a major cause is genetic predisposition.

In case of diabetes
occurring in adults, the shortage of insulin is only relative, whereas
in the diabetes occurring in the young, known as type-I diabetes, the
islet cells of the pancreas are destroyed due to the auto-immune
phenomena (body reacting to its own tissues) and insulin is not
available. That is why the later variety is also known as
insulin-dependent diabetes, meaning, thereby, that in this kind of
diabetes, administration of insulin is mandatory. I am oversimplifying
this classification as there is a lot of overlapping between the two.
But that is more for the experts.

The glucose level is
regulated by hormones like insulin, glucagon, adrenaline and to some
extent other adrenal hormones. Insulin and glucagon are the two main
hormones which maintain the level of blood glucose within the normal
range. Insulin is produced by the body when there is an intake of
carbohydrates and glucagon is produced when there is a shortage of
glucose. In other words, one is for the feast and the other one is for
the fast. The metabolism is much more complex than this with various
other factors coming into play. But the end result is that the body is
unable to regulate its glucose levels in this disease for one reason
or the other.

Besides the genetic
predisposition and auto-immune process causing diabetes, the factors
which enhance the predisposition to this disease are obesity,
hypertension, lack of physical activity, malnutrition, various
hormonal disturbances and drugs. A relatively new observation has been
made that it is not only obesity which is an important factor, but the
distribution of fat is also important. Excessive fat deposit in the
middle of the body predisposes a person to diabetes and this kind of
fat distribution is highly prevalent among Indians all over the world.
This pattern of obesity seems to promote resistance to insulin, which
is the first step in type-II diabetes mellitus.

Magnitude of theproblem

The incidence of
diabetes is increasing by leaps and bounds and in my own professional
career spanning four decades, the incidence in the adult population
seems to have gone up from nearly 2 per cent to the present estimated
15 per cent in the urban population and about 8-10 per cent in the
rural population. At present, there are nearly 30 million diabetics in
India out of an over 100 million global diabetic population. By the
next 20-25 years, it will grow nearly to 70 million in India and about
150 million globally. We will, therefore, be harbouring nearly half of
the world’s diabetics. This will be coupled with another distinction
of being the most populated country. It is not, however, sparing the
developed countries either. In one of the September, 2000, issue, the Time
Magazine lamented about the diabetic explosion in the USA,
summarising that the USA is getting fatter and fatter and diabetes is
occurring in younger and younger victims and the incidence there has
grown from 4.9 per cent to 6.5 per cent during the past decade, an
increase of nearly 33 per cent to 35 per cent. During the same period,
the level of obesity has gone up with 44 per cent to 54 per cent
Americans being overweight and nearly 20 per cent being technically
obese. The weight and diabetes seems to go fairly parallel.

Recognition or
diagnosis

It is an amazing
disease in clinical medicine. The type-I or the insulin-dependent
diabetes can be recognised even by a medical student by its classic
combination of polyuria, polydysia, polyphagia (meaning excessive
urine, thirst, hunger) and loss of weight. In the second variety of
diabetes, the onset is insidious, silent and can present itself with
serious complications for the first time. This deceptive clinical
picture has earned it the dubious label of ‘silent killer’. Every
adult, therefore, should be alert to its onset and presence
particularly if there is a family history of diabetes, obesity,
propensity to repeated infections, presence of heart disease, high
blood pressure, any eye problem, stroke, numbness of the limbs or
gangrene of one of the toes or foot. The last few mentioned
complications will, of course, leave no choice and person will be
forced to seek medical attention. But it is the first few
accompaniments which should make a person look for it and there is
nothing like a periodical medical check-up, may be once a year.

It is not my
intention to go into the details of the medical aspects of diabetes
and its complications which need a lot of professional input. I would
like to mention that great advances have been made in the treatment of
diabetes, including the purification of insulin, the development of
human insulin, very easy delivery system like pre-packed syringes and
insulin pumps. A large number of oral drugs have come in rapid
succession, making it easier to control this disease. Lot of research
has been done in the transplanting of the tissue producing insulin,
including the transplant of the pancreas itself and now efforts are
being made to transplant the insulin-producing islet cells.

Genetics of this
disease are being explored and with the stupendous discovery of human
genome, one hopes that more light will be shed on the inheritance of
this disease. Having said that, I would like to add that the drug
treatment of diabetes is only one and perhaps a small component of
treatment of diabetes. What is needed is a wholesome discipline in
nutrition, physical exercise, weight control, with no smoking and no
alcohol. It has now been shown fairly convincingly by a large number
of trials that a tight control of diabetes would minimise various
complications of diabetes and the effort is worth it.

Prevention

Considering the above
facts, preventive steps in diabetes are of paramount importance.
Prevention does not necessarily mean that this can be prevented in the
absolute sense. If there is a strong family history or if one is
unfortunate to develop the auto-immune disorder affecting the islets
cells, this may not be possible. The prevention in this respect means
taking steps to delay its onset, prevent complications by good control
and finally to tackle these complications in time, if and when these
arise. It means keeping the weight within limits by dietary and
physical effort, a regular check-up for early detection and setting
the goal for tight control by regular medical supervision. In fact,
therapeutic as well as preventive measures at each stage of this
disease go hand in hand. Diabetes affects virtually every cell of the
body but its special targets are the heart, brain, eyes, kidneys,
nerves and sexual function.

Nevertheless, one is happy to strike
a positive note at the end that numerous patients live a very happy,
well-adjusted and full life with a disciplined approach to this
disease. Let us start doing it and see the result.

Checklist for
potential diabetics

Family
history of diabetes.

In a child
or young person, excessive thirst, appetite, urine or weight
loss.

Obesity,
especially central obesity.

High blood
pressure, heart disease strokes, high cholesterol or their
combination.